Selected DSM-5 Assessment Measures
DESPITE the popular perception that the DSM texts are chiseled in stone, the authors of DSM-5 (American Psychiatric Association 2013) describe the manual as subject to constant revision and have plans to update it in response to growing scientific knowledge. This commitment reaffirms that DSM is a pragmatic text for current clinical use (Kinghorn 2011). DSM-5’s pragmatism extends to the authors’ planning for its eventual successors. In DSM-5 Section III, “Emerging Measures and Models,” the authors include several assessment tools, rating scales, and alternative diagnoses. Taken together, these constitute both valuable tools for current use and possible ways forward for DSM as a diagnostic system.
Currently, the main text of DSM-5 preserves the categorical model of mental illness. In this model, a person must meet certain criteria to have a mental illness on the basis of the presence or absence of symptoms. The categorical model was first introduced in DSM-III (American Psychiatric Association 1980) and is widely recognized for its improved diagnostic reliability, or in other words, the likelihood of different practitioners agreeing on the same diagnosis for a particular person. One shortcoming of this model is limited diagnostic validity—that is, the ability of practitioners to make an accurate diagnosis (Kendell and Jablensky 2003).
Each of the tools in Section III of DSM-5 attempts to improve the reliability and validity of psychiatric diagnoses. These tools are diverse, and we find that each one provides ways for practitioners to personalize the diagnostic criteria for particular patients.
In this chapter, we introduce several of these measures that can be useful in clinical practice with older adults.
Level 1 and Level 2 Cross-Cutting Symptom Measures
Most people first seek help for mental distress from someone they already know, often a primary care physician, clinic nurse, home health aide, or other practitioner whose training is outside mental health. In fact, most mental health care occurs outside the offices of mental health practitioners. To address the gap between the mental health training of non–mental health practitioners and the volume of mental health care they provide, DSM-5 offers screening tools—the Level 1 and Level 2 Cross-Cutting Symptom Measures—for use in either primary care or mental health settings. These brief, easy-to-read, paper-based tools can be completed before a clinical encounter, either by the patient or by someone who knows her well. The tools, which are available in Section III of DSM-5 and online at www.psychiatry.org/dsm5, can be reproduced and used, without additional permission, for clinical and research evaluations.
Each of these tools has a series of questions about recent symptoms (e.g., the Level 1 Cross-Cutting Symptom Measure—Adult asks, “During the past two  weeks, how much [or how often] have you avoided situations that make you anxious?”). These screening questions assess core symptoms for the major diagnoses. For example, for each Level 1 symptom statement, a patient or her caregiver will assess how much this bothered the patient using a 5-point scale: none (0), slight (1), mild (2), moderate (3), or severe (4). Each tool is designed to be easily scored. If a patient reports a clinically significant problem in any domain, you should consider a more detailed assessment tool (e.g., one designed for assessing anxiety).
The initial assessment to use with older adults is the Level 1 Cross-Cutting Symptom Measure—Adult, which contains 23 questions to be completed by the person seeking assessment before an initial evaluation or by the caregiver of an older adult. For most, but not all, of the symptom domains screened for in the Level 1 tool, there are separate Level 2 Cross-Cutting Symptom Measures for specific areas of concern, including depression, anger, mania, anxiety, somatic symptoms, sleep disturbances, repetitive thoughts and behaviors, and substance use.
Level 1 and 2 assessments initially help a practitioner identify and characterize the presenting problems. After the initial assessment, they can be used to help measure treatment response and progress toward recovery. The authors of DSM-5 suggest using the Cross-Cutting Symptom Measures at the first evaluation of a patient, in part to establish her baseline, and then revisiting that assessment periodically to assess her progress. These measures assess dimensions rather than diagnoses, which means they are not designed to tell the degree of likelihood of identifying a specific diagnosis. Their strength is that they allow you to track different symptom domains (e.g., the depressive symptoms of a patient with schizophrenia in addition to her psychotic symptoms).
Systematic use of these cross-cutting assessments will alert you to significant changes in a patient’s symptomatology and will provide measurable outcomes for treatment plans. They also may alert researchers to lacunae in the current diagnostic system.
For your convenience, the Level 1 tool appears in Figure 11–1. Practitioners using the Level 1 tool are encouraged to further explore all reports of problems with inattention, psychosis, substance use, and suicidal ideation or attempts, even those rated as 1 (slight). For the other domains, practitioners are encouraged to explore symptoms rated 2 (mild) or greater. The Level 2 measures are easily accessed online at www.psychiatry.org
Cultural Formulation Interview
Another way the authors of DSM-5 have attempted to improve the diagnostic system is by attending to the cultural specificity of mental distress and illness. Asking about a patient’s and caregiver’s cultural understanding of sickness and health is an efficient way to build a therapeutic alliance while gathering pertinent information (Lim 2015). In addition, performing a cultural assessment also personalizes the diagnosis, which increases its accuracy (Bäärnhielm and Scarpinati Rosso 2009). In Section III of DSM-5, “Cultural Formulation” (pp. 749–759), the authors discuss cultural syndromes, idioms of distress, and explanations of perceived causes.
Before we discuss using this cultural information in an interview, we should first define a few terms. A cultural syndrome is a group of clustered psychiatric symptoms specific to a particular culture or community. The syndrome may or may not be recognized as an illness by members of a community or by observers. A classic example is ataque de nervios, a syndrome of mental distress characterized by the sudden onset of intense fear, often experienced physically as a sensation of heat rising in the chest, that may result in aggressive or suicidal behavior (Lewis-Fernández et al. 2015). The syndrome is often associated with familial distress in Latino communities (Lizardi et al. 2009). A cultural idiom of distress, such as ataque de nervios, is a way of discussing mental distress or suffering shared by members of a particular community. Finally, a cultural explanation or perceived cause provides an explanatory model of why mental distress or illness occurs (American Psychiatric Association 2013). By its authors’ own admission, DSM-5 is one culturally shaped way of accounting for distress; the authors state, “The current formulation acknowledges that all forms of distress are locally shaped, including the DSM-5 disorders” (American Psychiatric Association 2013, p. 758). So how do you acknowledge the effects of culture on distress?
The Cultural Formulation Interview (CFI) is a structured tool, updated for DSM-5, to assess the influence of culture in a particular patient’s experience of distress. You can use the CFI at any time during an interview, but the authors of DSM-5 suggest using it when a patient seems disengaged, when you are struggling to reach a diagnosis, or when you are laboring to assess the dimensional severity of a diagnosis. Although use of the CFI has been studied mostly in immigrant communities (Martínez 2009), you should not limit its use to situations in which you perceive the patient as culturally different from yourself. You can use the CFI profitably in any setting because “cultural” accounts of why people get ill and why they return to health occur not only in immigrant communities but in all communities. Even when you believe that a person shares your own cultural account of illness and health, she may have a very different understanding of why people become ill and how they can become well. Furthermore, the CFI is the most patient-centered portion of DSM-5, and using it particularizes the diagnostic process.
The CFI is not a scored system of symptoms but rather a series of prompts to help you assess how a patient understands her distress, its etiology, its treatment, and the prognosis. The CFI can be incorporated into a diagnostic examination to personalize the diagnosis and build a therapeutic alliance. If you want to learn more about the CFI, you should review the materials in Section III of DSM-5 or read the DSM-5 Handbook on the Cultural Formulation Interview (Lewis-Fernández et al. 2015). The following is as an operationalized adaptation divided into five themes. Just as in the rest of this book, the italicized portions are interview prompts.
Introduction: I would like to understand the problems that bring you here so that I can help you more effectively. I want to know about your experience and ideas. I will ask some questions about what is going on and how you are dealing with it. There are no right or wrong answers. I just want to know your views and those of other important people in your life.
Cultural definition of the problem: What problems or concerns bring you to the clinic? What troubles you most about your problem? People often understand their problems in their own way, which may be similar to or different from how doctors explain the problem. How would you describe your problem to someone else? Sometimes people use particular words or phrases to talk about their problems. Is there a specific term or expression that describes yours? If yes: What is it?
Cultural perceptions of cause, context, and support: Why do you think this is happening to you? What do you think are the particular causes of your problem? Some people may explain their problem as the result of bad things that happen in their life, problems with others, a physical illness, a spiritual reason, or some other cause. Do you? What, if anything, makes your problem worse, or makes it harder to cope with? What have your family, friends, and other people in your life done that may have made your problem worse? What, if anything, makes your problem better or helps you cope with it more easily?
Role of cultural identity: Is there anything about your background—for example, your culture, race, ethnicity, religion, or geographical origin—that is causing problems for you in your current life situation? If yes: In what way? On the other hand, is there anything about your background that helps you to cope with your current life situation? If yes: In what way?
Cultural factors affecting self-coping and past help seeking: Sometimes people have various ways to make themselves feel better. What have you done on your own to cope with your problem? Often, people also look for help from other individuals, groups, or institutions to help them feel better. In the past, what kind of treatment or help from other sources have you sought for your problem? What type of help or treatment was most useful? How? What type of help or treatment was not useful? How? Has anything prevented you from getting the help you need—for example, cost or lack of insurance coverage, getting time off work or family responsibilities, concern about stigma or discrimination, or lack of services that understand your language or culture? If yes: What got in the way?
Cultural factors affecting current help seeking: Now let’s talk about the help you would be getting here from specialists in mental health. Is there anything about my own background that might make it difficult for me to understand or help you with your problem? How can I and others at our facility be most helpful for you? What kind of help would you like from us now?
Conclusion: Thank the person for participation, summarize the main findings, and transition back to the remainder of your interview.